Penetrating atherosclerotic aortic ulcer

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Penetrating atherosclerotic aortic ulcer
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor-In-Chief: Sahar Memar Montazerin, M.D.[2] Cafer Zorkun, M.D., Ph.D. [3]

Synonyms and Keywords: : Penetrating aortic ulcer

Overview

Penetrating atherosclerotic aortic ulcer is ulceration of atheromatous plaque that has eroded the inner, elastic layer of the aortic wall, reached the medial layer, and produced a hematoma in the media.

Historical Perspective

  • In 1934, Dr. Shennan was the first to describe the term "penetrating atherosclerotic aortic ulcer".[2]
  • In 1986, Dr. Stanson further defined this disorder.[3]

Classification

  • Penetrating atherosclerotic aortic ulcer is classified similarly to the aortic dissection.
  • Learn more about the classification of aortic dissection by clicking here.

Pathophysiology

Causes

Differentiating Penetrating Atherosclerotic Aortic Ulcer from other Diseases

Epidemiology and Demographics

  • The exact prevalence of penetrating atherosclerotic aortic ulcer is unknown.
  • The incidence of penetrating atherosclerotic aortic ulcer is 1.62 per 100,000 individuals worldwide.[5]
  • Unlike typical aortic dissection, penetrating atherosclerotic aortic ulcers most often occur in elderly patients with severe underlying atherosclerosis.[4]
  • It usually affects people in their seventh decade of life or when older. [3]
  • Penetrating atherosclerotic aortic ulcer affects men at a greater extent than women.

Risk Factors

Screening

  • There is insufficient evidence to recommend routine screening for penetrating atherosclerotic aortic ulcer.

Natural History, Complications, and Prognosis

Diagnosis

Diagnostic Study of Choice

  • Table below provides a comparison of diagnostic imaging studies for the diagnosis of penetrating atherosclerotic aortic ulcer:[10]
Diagnostic Modality Diagnostic Value
  • Moderate
  • Moderate
  • Excellent
  • Excellent

History and Symptoms

Physical Examination

Laboratory Findings

  • There are no diagnostic laboratory findings associated with penetrating atherosclerotic aortic ulcer.

Electrocardiogram

  • There are no ECG findings associated with penetrating atherosclerotic aortic ulcer.
Penetrating atherosclerotic aortic ulcer[12]

X-ray

Echocardigraphy

CT Scan

  • CT scan imaging with intravenous contrast is the diagnostic study of choice for diagnosis of penetrating atherosclerotic aortic ulcer.[7]
  • Findings suggestive of penetrating atherosclerotic aortic ulcer include a localized ulcer passing from intima into aortic wall or contrast leak through a calcified plaque.
  • It usually affects mid to distal third of descending aorta.
  • Ulcer is usually defined by focal thickening or enhancement of the aortic wall.
contrast-enhanced CT[16]

MRI

  • MRI study is superior to conventional CT scan in the diagnosis of penetrating atherosclerotic aortic ulcer.[17]
  • Finding suggestive of the diagnosis includes a well-defined ulcer with flow void phenomenon on T1 images.

Other Imaging Findings

  • Findings associated with penetrating atherosclerotic aortic ulcer on a CT angiography may include the presence of false aneurysm.

Other Diagnostic Studies

  • There are no other diagnostic studies associated with penetrating atherosclerotic aortic ulcer.

Treatment

Penetrating aortic atherosclerotic ulcer with false aneurysm[18]

Medical Therapy

  • The treatment aims at preventing the penetrating atherosclerotic aortic ulcer to progress into aortic dissection. Indications for treatment interventions include recurrent and refractory pain, signs of contained rupture, rapidly growing aortic ulcer, and presence of periaortic hematoma or pleural effusion.[19][20]
  • Early interventions are indicated in ulcer with a diameter greater than 20 mm.

Surgery

  • Surgical interventions may be indicated in penetrating atherosclerotic aortic ulcer depending on the anatomic location of the ulcer, clinical presentation and comorbidities. However, since most of the patients are poor surgical candidates due to advanced age and associated comorbidities, thoracic endovascular aortic repair (TEVAR) is used more frequently.[20][21]

Primary Prevention

  • There are no established measures for the primary prevention of penetrating atherosclerotic aortic ulcer.

Secondary Prevention

  • There are no established measures for the secondary prevention of penetrating atherosclerotic aortic ulcer.

Guidelines

2014 ESC Guidelines on the Diagnosis and Treatment of Aortic Diseases (DO NOT EDIT)[10]

Recommendations Class Level
I C
  • "In the case of Type A PAU, surgery should be considered."
IIa C
  • "In the case of Type B PAU, initial medical therapy under careful surveillance is recommended."
I C
I C
  • "In complicated Type B PAU, TEVAR should be considered."
IIa C
  • "In complicated Type B PAU, surgery may be considered."
IIb C

Abbreviations: CT: computed tomography; MRI: magnetic resonance imaging; PAU: penetrating aortic ulcer; TEVAR: thoracic endovascular aortic repair.

See Also

External Links

References

  1. Case courtesy of Dr Vincent Tatco, Radiopaedia.org, rID: 48455
  2. Peery, Thomas M. (1936). "Dissecting aneurysms of the aorta". American Heart Journal. 12 (6): 650–665. doi:10.1016/S0002-8703(36)91001-3. ISSN 0002-8703.
  3. 3.0 3.1 3.2 3.3 3.4 Stanson, Anthony W.; Kazmier, Francis J.; Hollier, Larry H.; Edwards, William D.; Pairolero, Peter C.; Sheedy, Patrick F.; Joyce, John W.; Johnson, Michaël C. (1986). "Penetrating atherosclerotic ulcers of the thoracic aorta: natural history and clinicopathologic correlations". Annals of Vascular Surgery. 1 (1): 15–23. doi:10.1016/S0890-5096(06)60697-3. ISSN 0890-5096.
  4. 4.0 4.1 4.2 Kotsis, Thomas; Spyropoulos, Basileios Georgiou; Asaloumidis, Nikolaos; Christoforou, Panagitsa; Katseni, Konstantina; Papaconstantinou, Ioannis (2019). "Penetrating Atherosclerotic Ulcers of the Abdominal Aorta: A Case Report and Review of the Literature". Vascular Specialist International. 35 (3): 152–159. doi:10.5758/vsi.2019.35.3.152. ISSN 2288-7970.
  5. 5.0 5.1 DeMartino, Randall R.; Sen, Indrani; Huang, Ying; Bower, Thomas C.; Oderich, Gustavo S.; Pochettino, Alberto; Greason, Kevin; Kalra, Manju; Johnstone, Jill; Shuja, Fahad; Harmsen, W. Scott; Macedo, Thanila; Mandrekar, Jay; Chamberlain, Alanna M.; Weiss, Salome; Goodney, Philip P.; Roger, Veronique (2018). "Population-Based Assessment of the Incidence of Aortic Dissection, Intramural Hematoma, and Penetrating Ulcer, and Its Associated Mortality From 1995 to 2015". Circulation: Cardiovascular Quality and Outcomes. 11 (8). doi:10.1161/CIRCOUTCOMES.118.004689. ISSN 1941-7713.
  6. Coady, Michael A.; Rizzo, John A.; Elefteriades, John A. (1999). "PATHOLOGIC VARIANTS OF THORACIC AORTIC DISSECTIONS". Cardiology Clinics. 17 (4): 637–657. doi:10.1016/S0733-8651(05)70106-5. ISSN 0733-8651.
  7. 7.0 7.1 7.2 Hayashi, Hideyuki; Matsuoka, Yohjiro; Sakamoto, Ichiro; Sueyoshi, Eijun; Okimoto, Tomoaki; Hayashi, Kuniaki; Matsunaga, Naofumi (2000). "Penetrating Atherosclerotic Ulcer of the Aorta: Imaging Features and Disease Concept". RadioGraphics. 20 (4): 995–1005. doi:10.1148/radiographics.20.4.g00jl01995. ISSN 0271-5333.
  8. Ueda, Takuya; Chin, Anne; Petrovitch, Ivan; Fleischmann, Dominik (2012). "A pictorial review of acute aortic syndrome: discriminating and overlapping features as revealed by ECG-gated multidetector-row CT angiography". Insights into Imaging. 3 (6): 561–571. doi:10.1007/s13244-012-0195-7. ISSN 1869-4101.
  9. Nathan, Derek P.; Boonn, William; Lai, Eric; Wang, Grace J.; Desai, Nimesh; Woo, Edward Y.; Fairman, Ronald M.; Jackson, Benjamin M. (2012). "Presentation, complications, and natural history of penetrating atherosclerotic ulcer disease". Journal of Vascular Surgery. 55 (1): 10–15. doi:10.1016/j.jvs.2011.08.005. ISSN 0741-5214.
  10. 10.0 10.1 Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Eggebrecht H, Evangelista A, Falk V, Frank H, Gaemperli O, Grabenwöger M, Haverich A, Iung B, Manolis AJ, Meijboom F, Nienaber CA, Roffi M, Rousseau H, Sechtem U, Sirnes PA, Allmen RS, Vrints CJ (November 2014). "2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC)". Eur. Heart J. 35 (41): 2873–926. doi:10.1093/eurheartj/ehu281. PMID 25173340.
  11. 11.0 11.1 Bossone, Eduardo; LaBounty, Troy M; Eagle, Kim A (2018). "Acute aortic syndromes: diagnosis and management, an update". European Heart Journal. 39 (9): 739–749d. doi:10.1093/eurheartj/ehx319. ISSN 0195-668X.
  12. Case courtesy of A.Prof Frank Gaillard, Radiopaedia.org, rID: 10163
  13. Eggebrecht, Holger; Baumgart, Dietrich; Schmermund, Axel; Herold, Ulf; Hunold, Peter; Jakob, Heinz; Erbel, Raimund (2003). "Penetrating atherosclerotic ulcer of the aorta: treatment by endovascular stent-graft placement". Current Opinion in Cardiology. 18 (6): 431–435. doi:10.1097/00001573-200311000-00002. ISSN 0268-4705.
  14. Kyaw, Htoo; Sadiq, Sanah; Chowdhury, Arnab; Gholamrezaee, Rashin; Yoe, Linus (2016). "An uncommon cause of chest pain – penetrating atherosclerotic aortic ulcer". Journal of Community Hospital Internal Medicine Perspectives. 6 (3): 31506. doi:10.3402/jchimp.v6.31506. ISSN 2000-9666.
  15. Sommer T, Fehske W, Holzknecht N, Smekal AV, Keller E, Lutterbey G, Kreft B, Kuhl C, Gieseke J, Abu-Ramadan D, Schild H (May 1996). "Aortic dissection: a comparative study of diagnosis with spiral CT, multiplanar transesophageal echocardiography, and MR imaging". Radiology. 199 (2): 347–52. doi:10.1148/radiology.199.2.8668776. PMID 8668776.
  16. Case courtesy of A.Prof Frank Gaillard, Radiopaedia.org, rID: 10163
  17. Harris, James A.; Bis, Kostaki G.; Glover, John L.; Bendick, Phillip J.; Shetty, Anil; Brown, O.William (1994). "Penetrating atherosclerotic ulcers of the aorta". Journal of Vascular Surgery. 19 (1): 90–99. doi:10.1016/S0741-5214(94)70124-5. ISSN 0741-5214.
  18. Case courtesy of A.Prof Frank Gaillard, Radiopaedia.org, rID: 10163
  19. Ganaha, Fumikiyo; Miller, D. Craig; Sugimoto, Koji; Do, Young Soo; Minamiguchi, Hiroki; Saito, Haruo; Mitchell, R. Scott; Dake, Michael D. (2002). "Prognosis of Aortic Intramural Hematoma With and Without Penetrating Atherosclerotic Ulcer". Circulation. 106 (3): 342–348. doi:10.1161/01.CIR.0000022164.26075.5A. ISSN 0009-7322.
  20. 20.0 20.1 Eggebrecht, Holger; Herold, Ulf; Schmermund, Axel; Lind, Alexander Y.; Kuhnt, Oliver; Martini, Stefan; Kühl, Hilmar; Kienbaum, Peter; Peters, Jürgen; Jakob, Heinz; Erbel, Raimund; Baumgart, Dietrich (2006). "Endovascular stent-graft treatment of penetrating aortic ulcer". American Heart Journal. 151 (2): 530–536. doi:10.1016/j.ahj.2005.05.020. ISSN 0002-8703.
  21. Demers, Philippe; Miller, D.Craig; Mitchell, R.Scott; Kee, Stephen T; Chagonjian, Lynn; Dake, Michael D (2004). "Stent-graft repair of penetrating atherosclerotic ulcers in the descending thoracic aorta: mid-term results". The Annals of Thoracic Surgery. 77 (1): 81–86. doi:10.1016/S0003-4975(03)00816-6. ISSN 0003-4975.




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